**5. Poor functional outcome**

**4.2. Digital amputations**

130 Essentials of Hand Surgery

flow through free flap, in increasing degrees of difficulty.

**4.3. Multiple fractures and soft tissue injuries**

Without doubt, amputations are challenging to the junior as well as the senior surgeon and the difficulty increases the more distal it is. Although replantation is the most obviously best option if it is possible and there are a number of good articles on the technique [34, 39, 40], a revision amputation may be performed with some tips and tricks in mind to maximize the function. In a ring avulsion injury where the skin and subcutaneous tissues are avulsed and the bone plus tendinous structures are intact, or not (Urbaniak II, III), a ring skin graft may be applied (**Figure 23**) and the use of some regenerating agents may prove to be helpful [41]. Wherever possible, the proximal interphalangeal (PIP) joint should be preserved, for a prosthesis is more functional at this level. Replantation of digits with amputations distal to the FDS insertion do better as opposed to zone 2 ones and Urbaniak advocates amputation [42]. In these instances, placing a full thickness skin graft in a ring fashion may be helpful because it is firmly adherent on its base, provides a good cosmetic outcome and is relatively easy to perform. Alternatively, an abdominal flap may be fashioned (**Figure 19**) or a venous

**Figure 23.** Ring full thickness skin graft (FTSG) in an avulsion amputation or a failed replant.

The key is to stabilize the bony structure as sturdily and speedily as possible. Once that is achieved, the soft tissue elements will fall into place and be relatively easier to repair and reconstruct. The servile Kirschner wire may prove to be very useful as do the miniexternal fixators from LINK®. It is extremely useful to master Lister's technique as well as polishing one's skills in applying a (minilocking) plate. We have found using bone grafts (synthetic) may aid A poor outcome is unintentional and part of a learning curve that a surgeon goes through. There are certain pointers to avoid, which ensure known complications (**Figure 25**) do not occur. Amongst these are:


but we must remember that if almost all is lost, whatever we salvage is a plus point. Having said that, there are some main points to bear in mind—the goal should be the "greatest total benefit for our patient" [45], which may be different in various countries, cultures and beliefs. Clear communication, an idea of what is feasibly possible and the likely end result are some of the factors to bear in mind when discussing options with the patient and their relatives.

Crush Injuries of the Hand Part II: Clinical Assessment, Management and Outcomes

http://dx.doi.org/10.5772/intechopen.78298

133

Roohi SA would like to thank Prof. Dr. Lim Beng Hai for his guidance as well as the use of some of his work in the figures as acknowledged. With gratitude to great teachers: Drs. Gill

The authors declare no conflict of interest and have not received any remuneration or benefit

**Acknowledgements**

**Conflict of interest**

RS, Shukur MH, and Pathmanathan V.

**Appendix & nomenclature**

K-wire: Kirschner wire

PT: post-trauma

ROM: range of motion

RTA: road traffic accident

2-PD: two-point discriminator ADM: abductor digiti minimi

DIPJ: distal interphalangeal joint FDP: flexor digitorum profundus FDS: flexor digitorum superficialis

MCPJ: metacarpophalangeal joint

MVA: motor vehicle accident

MESS: Mangled Extremity Scoring System

PIPJ: proximal interphalangeal joint

P: phalanx 1: proximal, 2: middle, 3: distal

from any entity for the writing or publication of this article.

**Figure 25. A:** extensor tendon repair with Vicryl 3/0 (yellow arrows)—it eroded the thin overlying dorsal skin. The screw heads (blue arrows) are way too big too. **B:** K-wires passed through the germinal matrix will result in nail deformities. **C, D:** an enormous K-wire driven through a 5-year-old's little finger causing sluggish venous return. **E:** wire removal decongests. **F:** a finer wire does the trick. **G:** no malrotation. **H:** on slight flexion, the malrotation of the ring is seen. **I:** full flexion reveals more.


Thus as can be seen, most of the adverse outcomes can be avoided. The hand surgeon has a multitude of options in resurfacing the hand. Though there are challenges to be overcome, present day microsurgical and other techniques together with biological options offer the hope of good functional outcome in crush injuries to the hand.
